# NTSB SEA98LA065: Kaman K-1200, N224GM, La Grande, OR, April 21, 1998 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: April 21, 1998, 10:30 local (17:30 UTC) - Place: La Grande, OR - Coordinates: 45.319408, -118.199119 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=45.3194&lon=-118.1991&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report February 15, 2001 - Report: Approved by Office Director - NTSB case key (mKey): 42776 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA98LA065 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/42776/pdf - Page: https://openairdocs.org/ntsb/SEA98LA065 ## Probable cause The pilot's inadvertent shutdown of the engine with the FUEL/OIL shutoff switch. Contributing to the accident were: the manufacturer's inadequate location and design of the FUEL/OIL shutoff switch; the FAA's inadequate determination of the type design's compliance with applicable airworthiness standards; and the helicopter's low altitude at the time of the power loss. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - nonmechanical, climb - engine shutdown - inadvertent, pilot in command (cause) - acft/equip,inadequate control location, manufacturer (contributing factor) - acft/equip,inadequate design, manufacturer (contributing factor) - acft/equip,inadequate compliance determination, faa(other/organization) (contributing factor) - altitude - low (contributing factor) - Forced landing, emergency descent/landing - Roll over, emergency landing ## Analysis The pilot reported that after takeoff, when he attempted to turn the particle separator off about 200 feet above ground level, he immediately got a low fuel pressure indication and the engine then lost power. The helicopter touched down hard and rolled on its side in the ensuing forced landing. The pilot stated he believed he had inadvertently turned the fuel shutoff switch to OFF, rather than the particle separator switch. These two on-off switches are separated by about 2 inches on the instrument panel, and both actuate on and off in a common direction and along a common axis; the switches differ by shape only. In a post-accident examination, investigators found the FUEL/OIL switch OFF and the adjacent PART SEP switch ON. No evidence of pre-existing mechanical problems with the engine was reported. The K-1200 received normal-category FAA type certification in August 1994. FAA airworthiness standards for type certification of normal-category rotorcraft (contained in 14 CFR 27) require cockpit controls to be 'located to...prevent confusion and inadvertent operation', as well as 'means to guard against inadvertent operation of each shutoff.' ## Factual narrative On April 21, 1998, approximately 1030 Pacific daylight time, a Kaman K-1200 "K-MAX" helicopter, N224GM, being operated by Grizzly Mountain Aviation of Prineville, Oregon, was substantially damaged in a forced landing following a loss of engine power approximately 15 miles west of La Grande, Oregon. The commercial pilot-in-command of the single-seat helicopter did not report receiving any injury in the accident. The 14 CFR 91 positioning flight originated at a logging camp approximately 1 mile from the accident site, and was en route to La Grande at the time of the accident. Visual meteorological conditions prevailed and no flight plan had been filed for the flight. The pilot reported: I took off from the job site...and called out the numbers for the power assurance check to the mechanic. The engine temp[erature] seemed a little high and he asked what all [sic] I had on. I told him I had only the particle separator on. I reached down and turned the particle separator off and immediately got low fuel pressure and [then] the engine quit. I was only about 200 feet AGL and I picked a spot and tried to autorotate. I hit hard and the aircraft rolled onto its right side. I got my seat belt loose and turned the batt[ery] switch [off] and got out of the aircraft. The only thing I can think of is that I turned the fuel off. The air was rough that close to the ground and I had hit a bump just as I was reaching down to turn the particle separator off and talking to the mechanic on the ground at the same time. The particle separator switch and the fuel control switch both work the same way but are shaped a little different. I was wearing flight gloves at the time and must [have] turned off the wrong switch. On his NTSB accident report, the pilot reported his flight experience as over 13,000 hours of rotorcraft time (of which over 11,000 hours was pilot-in-command), including 1,250 hours in the K-1200. The pilot held a flight instructor certificate with a helicopter rating. On-scene investigators did not report observing any evidence of mechanical anomalies with the helicopter's AlliedSignal T53-17A1 turboshaft engine. Review of the helicopter's maintenance records disclosed no evidence of recent problems with the engine, and indicated that the helicopter had recently received all required inspections. The pilot reported on his NTSB accident report that he took off with 1,400 pounds of Jet A fuel, and that no mechanical failure or malfunction was involved in the accident. On his NTSB accident report, the pilot recommended the following as to how this accident could have been prevented: By moving the particle separator ON/OFF switch to the right side of the inst[rument] panel. There is lots of room on the right hand switch panel. There is no reason for it to be next to the fuel [shutoff] switch. The fuel [shutoff] switch should have a guard on it. Post-accident photos of the helicopter's instrument panel taken by FAA investigators showed the FUEL/OIL switch, a two-position (on/off) lever-lock type switch, in the OFF position and the PART SEP switch, also a two-position (on/off) lever-lock type switch, in the ON position. Both switches are located in the lower left corner of the instrument panel, with the FUEL/OIL switch located approximately 2 inches directly above the PART SEP switch. Both switches throw in an up-and-down direction along a common axis, with the ON position being an upward throw and the DOWN position being a downward throw for both switches. The FUEL/OIL and PART SEP switches differ by shape, with the FUEL/OIL switch being triangular and the PART SEP switch being a "bullet" switch. Technical personnel from Kaman Aerospace Corporation, the helicopter manufacturer, reported that in a post-accident examination of the helicopter, in addition to the above they found the fuel shutoff valve in the ON position, and that the valve actuated properly when electrical power was applied. The K-1200 received FAA type certification (type certificate number TR7BO) as a normal-category helicopter on August 30, 1994 (the accident helicopter had been issued a normal-category FAA airworthiness certificate on April 25, 1997.) The type certificate data sheet (revision 1, dated March 10, 1997) lists the type's certification basis as 14 CFR 27, effective February 1, 1965, and amendments 27-1 through 27-28. Pursuant to this accident investigation, the NTSB investigator-in-charge of this accident reviewed the provisions of 14 CFR 27, "Airworthiness Standards: Normal Category Rotorcraft", and noted the following requirements: Sec. 27.777 Cockpit controls. Cockpit controls must be--(a) Located to provide convenient operation and to prevent confusion and inadvertent operation.... Sec. 27.1189 Shutoff means.... (b) There must be means to guard against inadvertent operation of each shutoff, and to make it possible for the crew to reopen it in flight after it has been closed.... ## Aircraft - Registration: [N224GM](https://openairdocs.org/deregistered/N224GM-1998-10-15), registration cancelled 1998-10-15, S/N A940022 (OpenAirDocs) - Reported make and model: Kaman K-1200 - Registry model: [Kaman Aerospace K-1200](https://openairdocs.org/model/kaman-aerospace-k-1200) (registry code 13027LS) (OpenAirDocs) - Category: Helicopter - Serial number: A94-0022 - Airframe hours: 1936 - Engines: Allied Signal T53-17A1 1500 horsepower turbo shaft - Damage: Substantial damage - Flight: Positioning, Part 91 - Registered owner: Grizzly Mountain Aviation - Airworthiness certificate: Standard, Normal - Last inspection: Continuous airworthiness, April 17, 1998, 22 hours before - Departed: STARKEY, OR - Destination: LA GRANDE, OR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; commercial; airplane ratings: single-engine land, multi-engine land, single-engine sea; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; flight hours: 13,000 total, 1,250 in this make and model, 11,000 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 180° at 5 knots, gusting 10 - Lowest ceiling: none - Temperature: 50 °F ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19980421013329A](https://openairdocs.org/incident/19980421013329A), Apr 21, 1998: Kaman K1200, La Grande, OR, Substantial damage. Accidently turned off fuel switch instead of particle seperator on climbout. Switches close together. Poor design. (.4)the pilot reported that after takeoff,… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.